History of mental illness and psychotherapy

A critical exploration of the history of the treatment of mental illness - implications for psychotherapy in the 21st Century.

Introduction

This account explores the history of psychiatric services from the Victorian asylums and institutions of the 19th Century through to the services provided in the present day as part of the Government’s modernisation agenda. It examines the role of psychotherapy and counselling over these times, with some exploration of the theories of human nature that underpin various models of therapy. After critically exploring the various models and approaches to psychiatry and psychotherapy, the account upholds the notion that integrative (transpersonal) models provide the most suitable way of working therapeutically in current mental health services.

Historical background

Mental health services entered the 21st Century with the legacy of the large psychiatric hospitals finally at an end. These institutions, originally products of a philanthropic ‘moral’ treatment ideology in the 19th Century (the provision of public asylums eventually being made compulsory by the 1845 Lunacy Act) survived well beyond their sell-by date. As great strides were made in the field of physical health, mental health remained as a neglected backwater, often referred to as a ‘Cinderella service’. A hundred years after the Lunacy Act, the NHS was born. The NHS inherited a mental health provision that had become over-crowded, un-therapeutic and steeped in institutionalisation as described by Goffman (1961) and others.

The development of psychotherapy also took place during this period. It would be wrong to say that it had no influence over the large hospitals but the influence it had was small. The hospitals always had an overall treatment ethos which favoured physical and medical treatments over psychological. The influence of psychotherapy is perhaps better described as a societal one.

The psychodynamic, or psychoanalytic, model originated in the work of Sigmund Freud (1856-1939). Freud’s model postulated that all human actions and experiences were strongly influenced by unconscious processes, which took place within a structured and dynamic ‘psyche’. (Frude, 1998, pg 15). Freud placed emphasis on biologically based instincts and suggested that the personality comprised three elements: the id, the superego and the ego. The id was said to drive people to seek pleasure via the ‘pleasure principle’ reckless, savage or lecherous behaviour could therefore be expected from those driven by unrestrained id impulses. The superego on the other hand, reflected internalised parental values and acted as a restraining force for the id. The superego was often believed to be the source of unwelcome guilt, which may be conscious or unconscious. Freud believed that the ego acted as a mediator between the two elements by attempting to satisfy the basic needs of the id without violating the rules or values established by the superego. Freud suggested that the personality developed through five psychosexual stages at which different needs and desires dominate. The oral, anal, phallic, latency and genital stages. Freud suggested that some people encounter difficulties in passing through these stages of psychosexual development, which in turn adversely affected the development of ego. Freud referred to repression and neurosis as sources of anxiety when these difficulties occur, depending on the nature of the conflict, the individual’s personality ‘to manage the anxiety’.

In attempting to deal with this anxiety, people set up ‘defence mechanisms’. This involves some degree of reality distortion in order to protect the ego. Depending on the severity of the distortion, defence mechanisms could precipitate neurotic problems. Freud believed that if the distortion were then to become extreme, this might result in disorientation and delusional symptoms. Freud’s approach in psychotherapy was to alleviate symptoms by bringing repressed fantasies and emotions into consciousness. Techniques such as free association, transference and the interpretation of dreams were all techniques used to support his labour. In terms of psychiatry, Freud followed a classic medical model in which people were pathologised as having an illness that needed to be cured.

Jung (1875-1961) was a Swiss psychiatrist who collaborated with Freud but believed that the sexual drive was one among many creative instincts. Jung was particularly interested in dream interpretation and of the client’s responses to visual images. Jung extended Freud’s beliefs about a person’s individual experiences to include the ‘collective unconscious’ a reservoir of the aggregated experience of the human race. Jung believed that universal components such as icons and archetypes recur repeatedly across cultures and over historical periods (Frude, 1998, pg 17). Alfred Adler (1870-1937) was another analytic associate of Freud who eventually also disagreed about the significance of the sexual drive. Adler was particularly interested in the relevance of the individual’s striving for control and power. As children are relatively powerless compared to adults, this could lead to an ongoing sense of inferiority, which may distort relationships with others. Adler was interested how individuals might overcompensate for perceived inferiority by becoming callous or self centred. Adler’s work in psychotherapy attempts to help the client to examine values relating to power and dominance.

Erik Erikson (1902-94) developed theories as a child analyst through his elaborate model of life stages from infancy through to old age. People need to pass successfully through these various stages in order for the ego to develop in a healthy way. Social constraints or psychological blockages create difficulties in any of these stages and the role of the therapist according to Erikson was to build a basic trust between client and therapist and therefore confidence. Melanie Klein (1882-1960) was particularly interested in working with children and even analysed her own at one stage. Klein believed that children experienced complex unconscious fantasies even within the first year of life. Klein shifted the belief in instinct-related tension and anxiety (Freudian theory) to focus instead on individual’s relationships with ‘objects’-including good and bad objects of love and loss (e.g. good breast/bad breast). John Bowlby furthered the development of the psychology of social relationships via on attachment theory (Bowlby, 1980). Bowlby’s psychoanalytic work was of vital importance in elaborating the theme of the lasting impact of early relationships, and has been applied to such issues as the development of romantic relationships, deficiencies in parenting and grief reactions in adults who have been bereaved.

Many of these psychoanalytic models and therapeutic practices have been criticised in recent years along the lines that they exaggerate the importance of an individual’s early experiences at the expense of failing to acknowledge the importance of cognitive and physiological factors. Others criticise psychoanalytic work as being too highly intensive and not cost-effective in relation to other forms of therapy. Freud’s ideas that neurosis was an illness to be cured was re-interpreted by the influence of Carl Rogers via the human Relations School. Rogers did not wish to pathologise his patients in this way. Rogers did not view emotional difficulties as an indication of illness. ’Patients’ became ‘clients’ with a need to be loved. When this was inadequately met, the result was confusion and pain. His views centred less on the tools of transference and counter-transference and more on the core values of genuineness, empathy, and unconditional positive regard (Kahn, 1991, pg 36).

Looking at both therapy and the large psychiatric hospitals in the 1960s, the situation was one made up of growth and decline. Therapy was certainly growing while the large hospitals were clearly declining. There was, however, little overlap between the two. Perhaps it was in the outpatients departments or in the psychologist’s clinic that the overlap occurred. However, the vast majority of people receiving specialist mental health services were offered drug therapy rather than psychotherapy.

Government policy to close the large hospitals was first announced through the famous ‘water towers’ speech given by the then Minister of Health, Enoch Powell, in 1962. The story of their gradual closure over the subsequent 40 years is well documented. Rogers and Pilgrim (1996) give four potential reasons for their closure. Firstly, they cite the ‘Pharmacological revolution’ suggesting that the run-down of the hospitals occurred because of the successful use by psychiatrists of major tranquillisers from the late 1950s onwards. Secondly, they speak of an ‘Economic determinism’ suggesting that the run-down occurred to save money as large hospitals were so costly to run and maintain. Thirdly, they feel that a change in focus for care occurred away from providing institutional care for long term residents, to concentrating on interventions in acute and primary care settings outside of the large institution, which is increasingly seen as un-therapeutic. Their final reason is what they call a ‘shift in psychiatric discourse’. They suggest that shifts in psychiatric knowledge and the object of interest of psychiatric practice was moving towards a new psychiatric eclecticism.

It has been argued that, although the large institutions gradually closed, the institutional practices were merely transplanted into the new community-based services. Whilst there is some truth in that assertion, the very fact that services had come out into the community led to a small decrease in the power of a medically dominated model of care. Patients were gradually referred to as clients and then as service users as they came into contact with mental health workers whose training and background was based more in a Rogerian humanistic model. Another big influence on the ‘community care’ workforce was Maslow (1968), whose ‘hierarchy of needs’ became increasingly influential in training courses. Maslow introduced ‘self-actualisation’ as the pinnacle of his hierarchy and thus moved substantially away from a pathological approach to people’s problems. Indeed, he moved the focus a little away from a problem-focused approach and laid the basis for a needs-based strengths-led approach.

The 1980s saw the birth of what has been described as the ‘Service user movement’ (Campbell 1999). Building on the work of such organisations as the Mental Patients Union and the Campaign Against Psychiatric Oppression, Survivors Speak Out emerged in the UK from the World Federation for Mental Health Congress in Brighton in 1985. Encouraged and supported by the Dutch Patients Councils, Advocacy Services and the User/Survivor Organisation ‘Clientenbond’ and also by Judi Chamberlin and her book ‘On Our Own’ (1977), service users and survivors across the UK have achieved a growing influence since that time. In particular, I feel that they have often been responsible for keeping alternative perspectives about mental distress on the agenda during a decade when the tree of psychiatric diagnosis and medication grew so large that it seemed to cut out the light for any other perspectives to grow.

In the 1990s, the work of two Dutch psychiatrists Romme and Escher (1993) led to the growth of the ‘Hearing Voices’ network. This work, which has the understanding of psychosis as its bedrock, has empowered both service users and mental health workers be more active and take control. The model is a self-help approach for ‘voice hearers’, which has three stages: recognition, acceptance and understanding, coping/living with the voices. The link across to psychotherapy is clear. Many other self-help and self-management programmes have subsequently been established. The Manic Depression Fellowship’s self-management programme is amongst the best known and well used. The strength of these approaches is that they have emerged from service users and clients themselves, facilitated by mental health workers.

Early in the 2000s, The British Psychological Society published its report Understanding mental illness: recent advances in understanding mental illness and psychotic experiences (June 2000). Richard Bentall was the chair of the working party for this important publication, which had a feel of psychology marshalling its forces at the start of a new century for a battle with psychiatry. Bentall subsequently produced ‘Madness Explained’ in 2003 and questions the very basis of the psychiatric classification system by exposing the lack of scientific rigour in such crucial areas as diagnosis and treatment. Bentall launches an all-out attack on the current 943-page version of the Diagnostic and Statistical Manual, DSM-1V-TR (2000).

New century, new Labour and the modernisation of services

At the dawn of the 21st Century, Porter (2002, p. 216) looks back and says:

‘For some the twentieth century brought Freud’s revelation of the true dynamics of the psyche; for others, psychoanalysis proved a sterile interlude, before neurophysiological and neurochemical understanding of the brain finally advanced and bore fruit in effective medications. Psycho-pharmaceutical developments certainly allow psychiatry itself to function better, but pacifying patients with drugs hardly seems the pinnacle of achievement and any claims as to the maturity of a science of mental disorders seem premature and contestable – witness the wholesale comings and goings of classifications from the Diagnostic and Statistical Manual.’

It is clear that neuroscience has not come up with the goods, and criticisms of psychiatry both from outside and inside its ranks, linked to a growing service user/client voice, has put ‘talking treatments’ very much in the frame. Service users, when consulted, consistently ask for less reliance on medication and more access to talking treatments. This is particularly so for oppressed groups such as service users from Black and Minority Ethnic communities. (Ferns 2005)

‘New’ Labour formed the government in 1997. They inherited a mental health service that was perceived to be failing. The media had published many stories in the 1990s of the failure or breakdown of community services. The Government’s solution to this situation was to prioritise mental health services for resources and action. This was something of a shock to a part of the health service that had always been used to be last in the queue. The modernisation agenda for mental health is embodied in the National Service Framework for Mental Health (Department of Health 1999). The Framework’s seven standards cross the whole of mental health, with standard one being about mental health promotion, combating discrimination and promoting social inclusion.

This is a bold move and has led to increased resources, interest and activity across the whole field of mental health. The actual way-of-working with service users that lies at the heart of the Framework is an empowering one. It is about identifying people’s needs and strengths, rather than concentrating on their problems and weaknesses.

The Sainsbury Centre for Mental Health (Department of Health 2004) has developed ‘ten essential shared capabilities’ for all mental health practice.

Essential Shared Capability Number 6 is ‘Identifying People’s Needs and Strengths’. This is described as:

‘Working in partnership to gather information to agree health and social care needs in the context of the preferred lifestyle and aspirations of service users their families, carers and friends.

The focus of this capability is on helping the service user and those involved with them to describe their experiences in such a way as to identify their strengths and formulate their needs. In order for this to be meaningful this must take a whole systems approach and take account of every aspect of the person’s life.’

(Dept of Health 2004, p. 16)

This emphasis on a client’s strengths again points up a move away from a ‘pathologising’ approach which has been perceived as leading to a feeling of hopelessness in mental health services, as illustrated by Perkins (2001) when she recounts all the things that psychiatrists tell their patients that they will never do. Perkins also represents an increasing number of mental health workers who are prepared to speak out about their mental health problems. Perkins is a psychologist, clinical director of an NHS Trust, as well as a user of mental health services. Mike Shooter, currently the Chair at the Royal College of Psychiatry, has also recently spoken out about his mental health problems. This active challenging of the stigma and discrimination is very much in line with current Government policy in health care and beyond. (Social Exclusion Unit 2004)

Recovery

The Recovery approach also lies at the heart of modern mental health services. Repper and Perkins reframe the approach of services towards recovery as:

‘In the mental health services we are used to thinking about people’s experience in terms of the supports and interventions that mental health workers provide. We think in terms of in-patient facilities, outreach services, medication, occupational therapy, art therapy, and ‘psychosocial interventions’. We think of symptom reduction and discharge as indices of success. This is the wrong place to start. Everyone who experiences mental health problems faces the challenge of recovery, i.e. rebuilding a meaningful and valued life. Whether a person’s problems are time-limited or ongoing, whether or not their symptoms can be eliminated, they face the task of living with, and growing beyond, what has happened to them. The help offered by mental health workers needs to be considered in terms of the extent to which they facilitate, or hinder, this process of recovery.’ (Repper J, Perkins R, 2003, p. 45)

Recovery is not the same as cure – it does not necessarily mean that all suffering or symptoms have disappeared. It is about growth and does not refer to an end product or a result. It can, and does occur without professional intervention. One major strength of recovery is that its vision is not limited to a particular theory about the nature and causes of mental health problems. In this way, the agenda can more easily be set by the client or service user.

Recovery is, of course, not specific to people with mental health problems. Recovery is about taking back control over one’s life. Recovery is not a linear process – relapse is not a ‘failure’, but part of the recovery process. This is helpful as mental health services have for too long thought of hospitalisation as a failure rather than an important part of acre when needed. Everyone’s recovery journey is different and deeply personal. There are no rules for recovery, no formula for ‘success’.

Recovery as described by Repper and Perkins is based on the many stories and accounts of people with mental health problems.

For example, Gay (2003) gives a comprehensive list of things that encouraged her recovery process. Family, friends, supportive mental health workers, taking time for herself, writing, going back to work, studying, talking about her experiences are just some of the things she mentions. She says:

‘I think everyone in life is going through some form of recovery process. I call it a process because it is on-going and always has the potential to develop and change. I can say that I now look forward to the future although I still have my off days when I think it would be easier to give up.’ (Gay 2003, p.16)

Chadwick (2002, p.13) even speaks about becoming better after psychosis than he and other friends/colleagues were before. He stresses the importance of cultivating a sense of purpose as a very potent therapeutic strategy. He also says:

‘In the end one has to find one’s own way to becoming fully functioning and productive as a person. The best perspective to encompass these journeys is probably a post-modern one, in that they (his friends/colleagues) have as individuals used all manner of different approaches to mental health, from medication to Cognitive Behavioural Therapy, spirituality, literature and occultism. No one solution has come through as the ‘answer’. Each person – with a bit of help from their friends and professionals – has found their own route out of the treacherous valley of insanity to become living proof that one can emerge more vitalised, more ‘fully rounded’ as the humanists would say, more creative and in a sense more truly oneself than one was before.’

Integrative (transpersonal) models

Service users, when consulted, consistently ask to be respected and for someone to listen to them. They also want more access to therapy and talking treatments. Another key factor that has also emerged from service-user led research is the importance of spirituality and religion to mental health service users. It is felt that spirituality has been ignored or suppressed in the past with forms of religion and belief being sometimes seen as part of the illness. (Faulkner and Layzell 2000)

This situation poses opportunities and challenges for psychotherapy. There are many more potential clients. But these are clients that may have been excluded from therapy in the past. One might also pose the question: What forms of talking treatment/therapy are most suited to this age?

Psychotherapy and counselling has had little impact on mainstream mental health until now. The more traditional forms of psychotherapy, deriving from Freud, Jung, Klein and others have taught us all a great deal about human growth and development, and the possibility of resolution of deep-seated emotional problems. My sense is that integrative, transpersonal models, of which Psychosynthesis is one, fit more clearly with the modern agenda for mental health and ways of working that are strengths-based and avoid the pathologising of clients.

This account has attempted to portray the history of mainstream psychiatric services, the changes in culture over time, and the move from stigma and discrimination towards inclusion and a more strengths-led approach. In line with this, the essay upholds the notion that the most suitable way of working therapeutically is within an integrative/transpersonal realm because this approach aligns itself more closely with strengths-led approaches.